Society of Gynecologic Oncology

Women Do Well Without Opioids after Gyn Surgery

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An 89% drop in opioid use with restrictive prescribing protocol

The amount of opioids prescribed after gynecologic surgery declined by almost 90% with few complaints from patients after implementation of a restrictive prescription protocol, as reported here at the Society of Gynecologic Oncology (SGO) meeting.

Over a 6-month period, the total opioid pill count declined by 89% as compared with historical prescribing practices. The total included a 73% reduction the number of pills dispensed after open surgery and 97% after minimally invasive procedures.

Patients undergoing ambulatory/minimally invasive procedures and with no history of chronic pain received only prescription-strength ibuprofen or acetaminophen at discharge. Those with a history of opioid exposure or chronic pain, received a 3-day supply (12 pills) of hydrocodone-acetaminophen (Norco) or oxycodone-acetaminophen (Percocet).

Patients undergoing open surgery received either nonopioid pain medication or a 3-day opioid prescription at discharge. If a patient used an opioid for pain in the previous 24 hours, then a 3-day supply consisting of 24 pills (two every 6 hours) was prescribed.

More than 90% of patients went home without an opioid prescription after minimally invasive procedures, and fewer than 5% of patients expressed dissatisfaction with their doctors’ prescribing practices under the restrictive prescribing protocol, said Jaron D. Mark, MD, of the Roswell Park Comprehensive Cancer Center in Buffalo, New York.

“We were quite surprised by how few inquiries and requests for medication we got from our patients,” said Mark. “We expected that we would be able to reduce use of opioids without detrimental consequences, but the extent to which our hypothesis was supported by these results was really striking.”

Principal investigator Emese Zsiros, MD, PhD, also of Roswell Park, said the key factor in reducing opioid use after gynecologic surgery was setting appropriate expectations about pain management in advance of surgery — for clinicians and patients.

A second study reported at SGO documented overprescribing of opioids for minimally invasive hysterectomy. Patients routinely went home with an opioid prescription, but almost a third used none of the pills. The vast majority of patients used only a portion of the prescription, reported Erica Weston, MD, of Johns Hopkins Hospital in Baltimore.

Data, Planning, Caution

Taken together, the two studies showed that most patients undergoing gynecologic surgery — open or minimally invasive — require little or no opioid medication, said invited discussant Sean C. Dowdy, MD, of the Mayo Clinic in Rochester, Minnesota. Availability and use of nonopioid alternatives and preoperative education of patients are critical elements in a strategy to reduce opioid use.

Dowdy called for the development of procedure-specific guidelines for opioid use, which he helped develop at Mayo and will describe in detail at an upcoming meeting. Noting the lack of guidance in the medical literature, Dowdy and colleagues reviewed historical data encompassing 2,500 patients, 25 procedures, and 10 subspecialties. They then performed a survey of outpatient opioid prescribing practices covering a similar number of patients, procedures, and subspecialties.

After reviewing the data, surgeons at Mayo implemented a restrictive prescribing protocol similar to the one described by Mark. Dowdy said they expect to cut opioid use by 1.5 million pills a year.

However, he cautioned against allowing the prescription pendulum to swing too far in the direction of restrictive practices.

“There is no question that our current state is overprescribing, but we need to be very careful not to overcompensate and move to a state of underprescribing,” said Dowdy. “These guidelines apply to acute, postsurgical pain. They do not apply to management of chronic pain and certainly not apply to patients in the palliative-care setting.

‘Ultra-Restrictive’

Prior to implementing the restrictive protocol, Mark and colleagues surveyed U.S. gynecologic surgeons about their opioid prescribing practices. For patients undergoing minimally invasive procedures, half the surgeons prescribed 15-20 opioid tablets at discharge, and another 28% wrote prescriptions for 21 to 40 pills. For patients undergoing open surgery, two thirds of surgeons prescribed 21-40 opioid tablets and discharge, and 13% prescribed more than 40 tablets.

The restrictive protocol was evaluated from June 2017 through January 2018 and included 337 patients. Investigators compared the results with a control group of 626 patients who underwent similar procedures in prior years.

Overall, the average number of opioid tablets prescribed at discharge declined from 31.7 to 3.5, an 89% reduction. The total reduction included a 73% decline in average pill count for patients who had open surgery (43.6 vs 11.6, P<0.001) and a 97% decrease among patients undergoing minimally invasive procedures (28.1 vs 0.9, P<0.001). The proportion of patients discharged with no opioid prescription after minimally invasive procedures increased from 19.6% to 92.6% (P<0.001).

The average number of opioid tablets prescribed for patients with no prior opioid use declined from 31.7 to 3.1 (P<0.001) and from 31.6 to 6.2 among opioid-dependent patients (P<0.001).

The proportion of patients requesting refills within 30 days after surgery did not change significantly. Mean postoperative pain scores were virtually identical before and after implementation of the restrictive prescribing protocol (P=0.34).

Unused Pills

Weston reported findings from a prospective cohort study involving 114 women who underwent minimally invasive hysterectomy. The patients received an average of 3 opioid doses while in the hospital, and all were discharged with opioid prescriptions, averaging 30 pills per prescription. Weston said 25 patients used no opioid medication during hospitalization.

The women were surveyed regarding opioid use at follow-up visits 1-2 weeks after surgery and again at 4-6 weeks. At the first follow-up, 45 patients (36.9%) reported no opioid use since discharge, and the median number of pills used across the entire cohort was nine. At the end of follow-up, 37 patients (32.5%) had used no opioids, and the median number of pills since discharge was 11 for all 114 patients.

“We found that 90% of the patients used 30 or fewer opioid tablets,” said Weston. “The strongest predictor of opioid use after discharge was opioid use during the inpatient stay.”

Weight Affects Survival in Cervical Cancer

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Overweight and underweight women with cervical cancer did not live as long as their normal-weight counterparts, according to the results of a retrospective cohort study.

The median overall survival time in overweight/obese women was 6 months shorter than in women of normal weight (22 versus 28 months). For underweight women, median overall survival time was cut in half (14 versus 28 months), reported Leslie Clark, MD, of the University of North Carolina at Chapel Hill, and colleagues.

Being overweight or underweight, as determined by body-mass index (BMI), was also associated with worse recurrence-free survival and disease-free survival, Clark and colleagues said in Gynecologic Oncology.

“In understanding the effect of BMI on cervical cancer outcomes, it is important to recognize that both extremes of weight appear to negatively impact survival. Optimizing weight in cervical cancer patients may improve outcomes in these patients.”

The study included 632 women diagnosed with cervical cancer and treated at the university from 2000 to 2013. Their BMI was calculated using height and weight measurements taken at initial presentation to the oncology clinic. Four percent of the women were underweight (n=24), 30% were normal weight (n=191), and 66% were overweight or obese (n=417).

The investigators looked for connections between BMI at time of presentation and survival, controlling for factors including age, race, smoking, cancer stage, tumor grade, and histology.

Being overweight or obese was associated with significantly reduced median overall survival time compared with normal weight (22 versus 28 months; P=0.031). For underweight women, the reduced survival time was more dramatic (14 versus 28 months;P=0.018).

Compared with for normal-weight women, median recurrence-free survival time was also significantly shorter in obese/overweight women (7.6 versus 25 months; P=0.009) and in underweight women (20 versus 25 months; P=0.026).

There was a borderline-significant trend toward worse disease-specific survival in overweight/obese women compared with those of normal weight (22 versus 28 months; P=0.089). For underweight women, the difference was significant (14 versus 28 months; P=0.042).

Potential Underlying Mechanisms

“A potential unifying hypothesis connecting both extremes of weight to poor cancer prognosis is chronic systemic inflammation,” Clark and colleagues wrote. “Both patients with cancer cachexia/sarcopenia and overweight/obese patients are in a heightened inflammatory state, which may lead to increased cell proliferation and inhibition of apoptosis.

“However, this is likely not the only mechanism of poor outcomes. Co-morbid medical conditions might account for some of the differences in survival, particularly in morbidly obese patients.”

 Limitations of the study included its retrospective nature and the fact that all patients were treated at a single institution, which means the results may not be broadly generalizable, the investigators said.

“This study shows that the extremes of weight are detrimental to survival in women with cervical cancer, and further investigation regarding the cause of poor prognosis is warranted. Providers should optimize weight in underweight and overweight/obese patients to attempt to improve outcomes in these women. Interventions that target nutritional counseling and physical activity should be explored in these populations,” Clark and colleagues concluded.

Corroborating Evidence

A similar study presented at the recent Society of Gynecologic Oncology meeting corroborates the results of Clark et al.

That study, conducted by Aida Moeini, MD, of the University of Southern California, Los Angeles, and colleagues, examined the effect of weight change over time on disease-free survival rates in 665 women with endometrial cancer.

At 5 years, disease-free survival had fallen well below 50% for women who had either lost or gained 15% or more of their body mass. For women in the smallest weight-change category, those who had lost or gained less than 7.5% of body mass, disease-free survival was about 80%, Moeini and colleagues reported.

“Our results demonstrated that endometrial cancer patients continued to gain weight after hysterectomy, and post-treatment weight change had a bi-directional effect on survival outcome.”